efr instructor trainer course registration form · course lesson guides and exams; access to the...
TRANSCRIPT
Emergency First Response Instructor Trainer Course Prerequisites:• Teaching Status Emergency First Response Primary Care/Secondary Care and Care for Children Instructor• Have issued 25 Completion Cards or taught at least 5 Emergency First Response courses• Have no verified quality assurance issues in the past 12 months
____________Day/Month/Year
Fee $675
Includes Emergency First Response materials: Instructor Trainer Manual (hard copy and digital versions), Instructor Course Lesson Guides and Exams; access to the online and practical portions of the course, and the EFR Instructor Trainer application fee.
Bring to practical workshop Emergency First Response Trainer Manual, a current/updated Emergency First Response Instructor Manual, and your completed knowledge review and marketing plan assignment.
How To Register: If registering by fax or mail, please submit this entire form, do not cut bottom portion off
• Phone at 800 337 1864 (US and Canada) or +1 949 858 7234, extension 2495• Fax to +1 949 267 1261• Mail to Emergency First Response 30151 Tomas, Rancho Santa Margarita, CA 92688-2125• Email to [email protected]
REGISTRATION FORM Please print clearly
Name _________________________________________________________________________ PADI # ____________________
Daytime Phone (________) ______________________________ Business Phone (________) ____________________________
Email _____________________________________________________________________________________________________
Emergency First Response®
Instructor Trainer CourseRegistration Form
PAYMENT METHOD Program Fee $675 USCheck must be payable to EFR in US dollars and drawn on a US bank.
MasterCard VISA American Express Discover Card
Card Number _________ _________ ________ ________
Card expiration date _________
Cardholder Name ____________________________________Please Print
Cardholder Address (If different from registrant)
_____________________________________________________
_____________________________________________________
Authorized Signature __________________________________
391DT (Rev. 05/19) Version 3.04 © Emergency First Response Corp. 2019
SHIP MATERIALS TO:
Name ____________________________________________
Address line 1 _____________________________________
Address line 2 _____________________________________
City ______________________________________________
Zip/Postal Code ___________________
Country ___________________________
14/11/2019
This course course has two segments, a self-study knowledge development segment online, and a practical workshop. To begin, go to the PADI Pros’ Site/Pro Development/EFR and select a date and location for the practical workshop. Once registered for this location, you will receive a link to the online segment you’ll complete before the practical workshop.
DEMALocation ___________________________________________________ Date: _____ ____